CMS Enforcement Is Escalating, and Medicare Advantage Plans Should Pay Attention

By early April 2025, CMS had already posted nearly $2.9 million in civil money penalties against MA/Part D organizations, essentially matching the entire full-year 2024 total. That is a strong signal that enforcement is not slowing down.

But the bigger issue is not just the amount of the penalties. It is what they reflect.

Recent CMS enforcement actions and audit activity point to a familiar pattern: plans are being exposed for operational breakdowns tied to cost sharing, eligibility, claims administration, and audit readiness. Compliance risk today is not only about responding well during an audit. It is about whether the underlying systems, data, and workflows are working properly before CMS ever gets involved.

The Risk Is Becoming More Visible

CMS's 2024 audit and enforcement data shows broad oversight across the market.

In 2024, CMS conducted 39 program audits across 36 parent organizations, covering 494 contracts and 87.6% of the Medicare Part C population. That level of coverage means audit exposure is no longer limited to a small group of plans. It is widespread and highly relevant across the industry.

The areas CMS reviews are core operational functions: grievances, appeals, coverage determinations, formulary and benefit administration, SNP care coordination, and compliance program effectiveness. These are not side issues. They are central to member experience and plan performance.

The Underlying Problems Are Operational

What stands out in CMS findings is that many issues are not obscure or technical in the narrow sense. They are operational failures that directly affect members.

CMS's report highlights issues such as inappropriate cost sharing, delays or denials of Part D medications, inaccurate eligibility profiles, and failures to properly track maximum out-of-pocket obligations. These types of breakdowns can quickly become audit findings, enforcement actions, and member-impact events.

A clear example was the $2 million CMP imposed on Centene in January 2025, tied to failures involving maximum out-of-pocket tracking and member cost-sharing limits.

Universe Files Remain a Major Pressure Point

Universe data continues to be one of the clearest indicators of audit readiness.

CMS's current audit process gives organizations limited opportunities to submit complete and accurate universes. Repeated failure can result in formal findings, including Invalid Data Submission (IDS) conditions. In practice, poor universe quality does more than create data issues. It can prevent CMS from properly testing operations and increase overall audit risk.

That is why universe validation should be treated as a frontline compliance control, not a last-minute audit task.

What Plans Should Do Now

Plans should be focused on strengthening controls before problems surface in an audit or enforcement action. That includes:

• →Validating universe files before submission
• →Tightening controls around cost sharing and MOOP accumulation
• →Monitoring eligibility and benefit configuration changes
• →Maintaining stronger audit trails
• →Regularly testing high-risk operational workflows

The Takeaway

CMS has made the direction clear: enforcement pressure is elevated, audit reach is broad, and operational weaknesses are becoming more expensive.

For Medicare Advantage plans, the priority should not just be preparing for the next audit. It should be strengthening the systems, data, and controls that determine compliance every day. Plans that act early will be in a stronger position to reduce exposure, protect members, and avoid preventable penalties.